Provider Demographics
NPI:1457488769
Name:JOHN'S RX DRUG, INC.
Entity Type:Organization
Organization Name:JOHN'S RX DRUG, INC.
Other - Org Name:JOHN'S RX DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:GROGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:507-629-3801
Mailing Address - Street 1:131 3RD ST
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:MN
Mailing Address - Zip Code:56175-1211
Mailing Address - Country:US
Mailing Address - Phone:507-629-3801
Mailing Address - Fax:507-629-4694
Practice Address - Street 1:131 3RD ST
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:MN
Practice Address - Zip Code:56175-1211
Practice Address - Country:US
Practice Address - Phone:507-629-3801
Practice Address - Fax:507-629-4694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118490183500000X
MN2012153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN401360300Medicaid
MN401360300Medicaid